Healthcare Provider Details

I. General information

NPI: 1043319148
Provider Name (Legal Business Name): COUNTY OF PULASKI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 08/11/2022
Certification Date: 08/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 CAMO CLAD DR PULASKI COUNTY AMBULANCE
MOUNDS IL
62964
US

IV. Provider business mailing address

PO BOX 52
MOUNDS IL
62964-0052
US

V. Phone/Fax

Practice location:
  • Phone: 618-342-6209
  • Fax: 618-342-6254
Mailing address:
  • Phone: 618-342-6209
  • Fax: 618-342-6254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code341600000X
TaxonomyAmbulance
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number
License Number State

VIII. Authorized Official

Name: TRACIE DAWN HAFFORD
Title or Position: DIRECTOR
Credential:
Phone: 314-677-0185